ICNP
®
terminological subgroup for palliative
care patients with malignant tumor wounds
Subconjunto terminológico CIPE
®para pacientes em
cuidados paliativos com feridas tumorais malignas
Maria Cristina Freitas de Castro1
Patrícia dos Santos Claro Fuly1
Telma Ribeiro Garcia2
Mauro Leonardo Salvador Caldeira dos Santos1
Corresponding author Maria Cristina Freitas de Castro Marquês do Paraná street, 303, 24033-900, Niterói, RJ, Brazil. mcristinafc13@yahoo.com.br DOI
http://dx.doi.org/10.1590/1982-0194201600047
1Universidade Federal Fluminense, Niterói, RJ, Brazil. 2Universidade Federal da Paraíba, João Pessoa, PB, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
Abstract
Objective: To develop and validate a terminological subgroup using the International Classification for Nursing Practice for palliative care patients with malignant tumor wounds.
Methods: A methodological study with an integrative literature review that searched empirical evidence related to malignant tumor wounds and nursing interventions for the management of symptoms in MEDLINE, CINAHL, LILACS and COCHRANE, time frame from 2002 to 2015. After crossing the evidence with 2013 ICNP® terms based on the Model 7 Axis, statements were prepared as diagnoses and nursing interventions, distributed according to basic human needs of the conceptual framework of Wanda Horta, and evaluated by experts. Results: From 51 affirmative diagnoses and 134 nursing interventions, 84.31%, and 91.04% were validated, respectively, establishing the subgroup.
Conclusion: The instrument may constitute an easy access reference for nurses, providing wound care based on evidence and a unified nursing language.
Resumo
Objetivo: Desenvolver e validar um subconjunto terminológico, utilizando a Classificação Internacional para Prática de Enfermagem para pacientes em cuidados paliativos com feridas tumorais malignas.
Métodos: Estudo metodológico com revisão integrativa da literatura, que busca evidências empíricas relacionadas às feridas tumorais malignas e intervenções de enfermagem para manejo dos sintomas, nas bases de dados MEDLINE, CINAHL, LILACS e COCHRANE, recorte temporal de 2002 a 2015. Após cruzamento das evidências com termos da CIPE® 2013, baseado no Modelo 7 Eixos, foram elaboradas declarações de diagnósticos e intervenções de enfermagem, distribuídas de acordo com necessidades humanas básicas do referencial conceitual de Wanda Horta e avaliadas por peritos.
Resultados: Das 51 afirmativas de diagnósticos e 134 intervenções de enfermagem, 84,31% e 91,04% foram validadas respectivamente, sendo elaborado o subconjunto.
Conclusão: O instrumento poderá constituir-se numa referência de fácil acesso para enfermeiros, propiciando um cuidado da ferida baseado em evidências e linguagem de enfermagem unificada.
Keywords
Nursing care; Palliative care; Nursing diagnosis; Wounds and injuries; Nursing process; Patient care bundles
Descritores
Cuidados de enfermagem; Cuidados paliativos; Diagnóstico de enfermagem; Ferimentos e lesões; Processos de enfermagem; Pacotes de assistência ao paciente
Submitted March 13, 2016 Accepted June 30, 2016
Introduction
Advances in cancer treatment provide a signifi-cant increase in survival of patients with cancer. According to the World Health Organization, in most of the world, most of these patients will al-ready be at an advanced stage of the disease when they are first seen by a health professional. For them, the only realistic treatment option is pain relief and palliative care.(1)
Five to ten percent of patients with advanced cancer will develop malignant tumor wounds during the last six months of life as a result of the primary or metastatic tumor.(2-4) The malignant
tumor wounds are formed by infiltration of ma-lignant tumor cells into the skin structure, with a break in the integrity of the skin due to uncon-trolled cell proliferation that the oncogenesis pro-cess induces.(5)
Despite the lack of accurate statistics on the in-cidence, the amount of time spent by nurses caring for these patients is recognized, in terms of evalua-tion and management of the wound, as well as psy-chosocial support.(3,4,6)
The Nursing Care System (NCS) presents itself as a nursing work organization tool, and the International Classification for Nursing Practice (ICNP®) emerges as a unifying frame-work of language in this area, providing a stan-dardized terminology of care that facilitates the communication of nurses among themselves and with other health professionals responsible for policy decisions, so that the data and result-ing information is used for plannresult-ing and man-agement of nursing care and the development of policies.(7-9)
Based on identified demand with the patients treated in a high complexity care oncology unit (Unacon),(10) the study aimed to answer the
ques-tion: “What nursing diagnoses and interven-tions can be attributed to patients in palliative care with malignant tumor wounds, based on scientific evidence?” Thus, the objective of this study was to develop and validate a terminology subgroup, using the International Classification for Nursing Practice, for patients in palliative
care with malignant tumor wounds. It seeks to contribute to decision making by nurses, based on evidence, that support effective and efficient nursing interventions for the management of symptoms, providing a consistent basis for the practice of nursing documentation and contrib-uting to patient safety.
Methods
This was a methodological, descriptive study with a quantitative approach, performed in a General Hospital registered as Unacon, and developed in four stages.
In the first stage, an integrative literature re-view was performed in MEDLINE, CINAHL, LILACS, and COCHRANE, to answer the fol-lowing question: “What nursing diagnoses and interventions can be attributed to patients in palliative care with malignant tumor wounds based on scientific evidence?” As inclusion crite-ria, a temporal cut from 2002 to 2015 was used, along with publications in English, Spanish, and Portuguese, online full text, and adherence to the theme. Exclusion criteria included publica-tions with the theme involving children and ad-olescents. Thus, 43 articles became part of the study, as described in figure 1.
To construct the subgroup the conceptual refer-ence of the Theory of Basic Human Needs was used, following the recommendation of the International Council of Nurses, which guides the use of theo-retical or conceptual models for better organization listed in the catalog.(7) From reading articles in the
historic stage of nursing, 30 pieces of empirical ev-idence were identified related to malignant tumor wounds. They have been organized into a framework for better identification. In the nursing diagnosis stage, the evidence was submitted to cross-map-ping with the 2013 ICNP® version,(11) following the
7-Axis Model, generating 51 affirmative diagnoses that were grouped by basic human needs.
In the stage of the care plan, nursing inter-ventions indicated for each diagnosis construct-ed were organizconstruct-ed in a framework, according to
its purpose in the care of the malignant tumor wound and, subsequently, the cross-mapping was performed in terms of ICNP®, developing 134 nursing interventions.
In the consulted articles, the most cited empir-ical evidence was: odor (100%), exudate (90%), psychosocial impact (93%), bleeding (83%), pain (76%), infection (74%) and necrosis (62%). Nurs-ing interventions were constructed from the nurs-ing diagnoses based on the most cited empirical evidence.
In the third stage, the validation of the ICNP® nursing diagnosis statement and interventions was performed, based on the opinion of expert nurses. Data collection occurred in November of 2014 to January of 2015.
The study included nine expert nurses, with a daily practice caring for cancer patients with malignant tumor wounds in palliative care, with practice areas in dermatological nursing (1), sur-gery (2), medical clinic (3), hematology (1), and emergency service (2). Experts were asked to give an opinion regarding their degree of agreement with regard to the statements, according to the following criteria: adequacy, relevance, clarity, precision, and objectivity. These criteria were
selected in order to cover representative aspects of this phenomenon, understanding, and appli-cability. The degree of expert agreement on each criterion was assessed using a Likert scale, with scores from 1 to 5, where 1 - Poor, 2 - Fair, 3 - Average, 4-Good, 5 - Excellent.
In the fourth stage, the instrument was de-veloped containing the validated diagnoses and nursing interventions with the terms of the 2013 ICNP® version,(7,11) organized according to the
postulates of the conceptual framework of Wan-da Horta.(9)
For data analysis, the concordance index (CI) of the participants was calculated by means of simple statistical analysis. For each degree of agreement, a classification has been defined as follows: 1 = 0; 2 = 0.25; 3 = 0.50, 4 = 0.75; and 5 = 1. We considered the statements which obtained an IC ≥ 0.8 in the overall average valid.
The development of the study followed the 466/2012 Resolution(12) of the National Council on
Research, which regulates research with human be-ings. It was approved by the Research Ethics Com-mittee of the institution on October 11, 2013, with protocol number: 422494. Participants signed the Terms of Free and Informed Consent form.
Figure 1. Strategy for article selection
829 articles excluded after applying the inclusion and exclusion criteria
29 articles excluded after reading abstracts 79 articles selected: MEDLINE (57),
CINAHL (20), LILACS (01) and COCHRANE(35)
50 articles selected: MEDLINE (34), CINAHL (14), LILACS (01) and
COCHRANE (01)
7 duplicate articles excluded 43 articles selected: MEDLINE ( 28),
CINAHL (13), LILACS (01) and COCHRANE (01)
43 articles selected for the study
Analysis of selected articles in full Articles found in databases: MEDLINE
(778), CINAHL (94), LILACS (01) andCOCHRANE (35)
Results
From the intersection of empirical evidence with the terms of the 2013 ICNP® version, following the 7-Axis Model 51 nursing diagnoses were de-veloped.
Following the recommendation of the In-ternational Council of Nurses, which guides the use of theoretical or conceptual models for a better organization listed in the catalog, the Theory of Basic Human Needs of Wan-da de Aguiar Horta was used as a concep-tual reference. Thus, after the composition of nursing diagnoses, these were distributed according to the physiological, psychosocial and psycho-spiritual needs. Among the psy-chobiological needs, nursing diagnoses were identified for neurological regulation, ther-mal regulation and elimination subgroups (Chart 1).
Of nursing interventions indicated for em-pirical evidence, most cited in the texts, 134 nursing interventions were developed, and of these, 122 were validated by experts (91.04%) (Chart 2).
Discussion
Among the 51 proposed nursing diagnoses, 43 were validated by experts, achieving ≥ 0.8 CI (84.31%).
The following diagnoses did not receive a score needed for validation: caregiver stress risk, spiritual distress, impaired family relationship, stigma, lack of social support, anger, impaired psychological condition, and shame.
Of the eight diagnostic statements that were not validated, six were related to the psychosocial domain, one to the psychobiological domain, and one to the psycho-spiritual domain. The psychosocial and spiritual nature of the patient are areas which are scarcely addressed by health professionals, and even professionals trained in palliative care realize the difficulty of analyzing, addressing, and integrating the different
dimen-Chart 1. Nursing diagnoses distributed according to the physiological, psychosocial and psycho-spiritual needs of the theory of basic human needs
Physiological needs Subgroup ICNP® Diagnosis Perception of sensory organs Wound pain
Cancer pain Nausea Foul odor Itching
Oxygenation Upper airway obstruction risk Vascular regulation Bleeding
Bleeding risk Hemorrhage Hemorrhagic risk Hydration Peripheral edema Feeding Impaired appetite Malignant wound
Maceration of the skin surrounding the wound
Physical integrity Risk of maceration of the skin surrounding the wound
Physical activity Fatigue Impaired mobility
Body care Impaired ability to perform hygiene Physical security / Environment Infection
Infection risk Septic shock Wound with secretion
Tumor wound infestation by fly larvae Sexuality Sexual behavior impaired Regulation: cell growth Healing
Impaired Wound Necrosis Sleep and rest Impaired Sleep Therapeutics Complex Care Provider Role
Caregiver Stress Risk Psychosocial needs
Subgroup ICNP® Diagnosis Leisure Social isolation
Impaired socialization Emotional security Anxiety
Low confidence Fear Anger Love and acceptance Stigma
Lack of social support Impaired family relationship Self-esteem, self-confidence and self-respect Low self-esteem
Negative Self-Concept Impaired Coping Process Depression
Hopelessness Disturbed body image Suffering
Impaired Psychological condition Shame
Liberty and participation Helplessness Health education/learning Health Knowledge Deficit Autorrealização Impotence
Psycho-spiritual needs
Subgroup ICNP® Diagnosis Religiosity/Spirituality Spiritual Distress
Chart 2. Validated interventions
ICNP® Nursing interventions for the diagnosis, “foul odor” 1- Apply wound dressing.
2- Do debridement.
3- Assess the need for debridement surgery. 4- Gently rub the wound with gauze dressing and saline. 5- Gently rub the wound with gauze dressing and solution to clean. 6- Irrigate the wound with saline solution in syringe with needle. 7- Authorize bathing the wound in the shower.
8- Apply topical antibiotic therapy. 9- Apply occlusive dressing wound.
10- Guide the wound exchange dressing every day. 11 - Instruct on wound care.
12- Manage the control of the foul odor at the wound site. 13- Implement aromatherapy at the wound site. 14- Encourage ability to perform hygiene.
15- Guide patient and family about the disposal of bandages after changing. 16- Instruct on odor control at home.
17- Ventilate the house when changing the dressing. 18- Evaluate the need to administer antibiotics. 19- Avoid demonstrating discomfort with the foul odor.
20- Provide instructional material on control of the foul odor at the wound site.
ICNP® nursing interventions for the diagnoses: “Anxiety”, “Low Self-Esteem,” “ Negative Self-Concept “, “Low Confidence”, “ Impaired Coping process”, “Depression”, “Helplessness”, “Hopeless”, “Stigma” “Lack of Social Support”, “Disturbed Body Image “, “Impotence”, “Fear”, “Anger”, “Impaired Socialization”, “Suffering”, “Impaired Psychological Condition” and “Shame”
1- Protect the patient’s autonomy.
2- Engage the patient in the decision-making process. 3- Develop ability to communicate with the patient. 4- Develop ability to communicate with family members. 5- Explain about the wound.
6- Refer to social services. 7- Refer for support group therapy. 8- Guide in relaxation technique. 9- Guide in music therapy. 10- Assess social support. 11- Promote social support. 12- Wound care.
13- Teach about the wound care.
14- Assess the psychosocial response to the instruction on the wound. 15- Provide emotional support.
16- Assess exhaustion. 17- Palliate. 18- Advise on hope. 19- Assess fear. 20- Assess self-image.
21- Assess psychological well-being. 22- Assess coping capacity. 23- Assess depression. 24- Assess expectations. 25- Advise on fear. 26- Assess suffering. 27- Assess stigma.
28- Teach adaptation techniques. 29- Identify psychosocial status. 30- Maintain dignity and privacy. 31- Promote self-esteem. 32- Promote social welfare. 33- Promote hope. 34- Reinforce personal identity. 35- Encourage socialization.
ICNP® nursing interventions for the diagnosis, “Wound with secretion” 1- Apply wound dressing.
2- Apply a drainage bag.
3- Maintain integrity of skin proximal to the wound site. 4- Apply topical antibiotic therapy.
5- Clean the wound with appropriate solution. 6- Manage control of secretion at the wound site. 7- Assess the need to administer antibiotics. 8- Instruct on wound care.
Nursing interventions for the diagnosis, “Bleeding” 1- Prevent bleeding at the wound site.
2- Apply a non-adherent wound dressing. 3- Compress with wound dressing. 4- Press the wound site.
5- Apply hemostatic agent at the wound site. 6- Apply cold compress on the wound. 7- Apply cold saline in the wound.
8- Implement care technique with malignant wound. 9- Instruct about wound care.
10- Instruct the patient how to prevent bleeding at the wound site. 11- Instruct family on how to prevent bleeding at the wound site. 12- Instruct the patient to control bleeding at the wound site. 13- Instruct the family to control bleeding at the wound site. 14- Provide instructional material on bleeding control at the wound site. 15- Plan action for bleeding at the wound site.
16- Assess the need for blood therapy. 17- Refer to the physician. 18- Refer to emergency service.
Nursing interventions for the diagnosis, “Wound pain” 1- Administer pain medication before caring for the wound. 2- Care for the malignant wound.
3- Moisturize the gauze dressing with saline before removal. 4- Clean the wound with saline solution in syringe with needle. 5- Use saline solution at a comfortable temperature for the patient. 6- Keep the wound moist.
7- Assessing the need for pain medication at the wound site. 8- Apply cold compress pad to the wound site.
9- Maintain the integrity of skin proximal to the wound site. 10- Treat condition of skin proximal to the wound site. 11- Control foul odor in the wound.
12- Assessing infection at the wound site. 13- Avoid handling wound if not necessary. 14- Teach about wound care.
15- Assess pain when changing wound dressing.
16- Provide instructional material for pain control at the wound site. Nursing interventions for the diagnosis, “Cancer pain” 1- Evaluate the pain.
2- Evaluate the need for pain medication. 3- Assess response to pain management. 4- Guide the patient about pain management. 5- Guide patient-controlled analgesia use. 6- Guide the family about pain management. 7- Promote the use of devices to aid memory. 8- Assess adherence.
9- Encourage family and patient participation in pain control. 10- Guide relaxation technique.
11- Guide music therapy. 12- Refer for physiotherapy.
13- Report to physician about pain control. 14- Provide instructional material on pain control.
and relief of local symptoms, which include odor reduction, management of exudates, pain relief, skin integrity maintenance around the wound, prevention and control of bleeding, de-bridement if indicated, reduction of the bacteri-al flora, and the use of appropriate products and supplies.(2-5,13-15)
It is a challenge for nurses to use appropriate interventions for the management of a malignant tumor wound, providing functional dressings, with comfort and relief to the patient.(2-5,13-15)
Knowing the treatment options increases the safety of the nurse at the time of eval-uation and development of the care plan. The evolution of these wounds is very fast, which implies constant assessment and pos-sible changes for every dressing.(2-5,13-15) Using
the subset constructed by means of study, the nurse may have a tool for clinical deci-sion making and managing care decideci-sions, which enables better organization of work and greater effectiveness in nursing actions.
Of the nine nurses who participated in the sur-vey, six were assigned to inpatient units and two nurses practiced in the emergency service. The peculiar characteristics and working conditions of these environments are factors that may have in-fluenced the non-validation of certain intervention statements.
The non-validation of some of both the diag-nostic and intervention statements indicates the need for further studies, considering the complexi-ty of care provided to clients in palliative care with malignant tumor wounds, and the diversity of work environments in which these patients may be inte-grated at different times during their clinical disease course.
Conclusion
The aim of this study was achieved, from the development of the subset of of diagnoses and nursing intervention statements that can serve as an easily accessible reference for nurses pro-viding care. Thus, individualized care plans can sions of the human being, especially in situations
that refer to mortality.
Studies reinforce that the complexity of the wound means a challenge for the lay caregiver and the patient during the caregiving. The time spent trying to manage the signs and symptoms, the con-stant and visible reminder of the progression of can-cer and terminal illness, exhibited by the wound, bring important repercussions on various aspects of their lives (physical, psychological, social, spiritual and economic).(4,5,13)
Stigma, anger, anguish and shame are aspects mentioned by authors that permeate the experi-ence of having a malignant tumor wound, resulting in an impact on mental and emotional well-being, and loss of patient dignity,(3,13,14) which indicate
the need of further reflection on these aspects by nurses involved in the care of these patients.
In hospitals, the environment where the instru-ment was administered, the patient and his family are cared for by a whole team, which may also have influenced the non-validation of these proposed di-agnoses, as in this context some questions do not emerge as priority.
Of the 134 developed nursing interventions, 122 obtained ≥0.8 CI (91.04%), while 12 reached <0.8 CI (8.96%). Among those which did not reach the ≤ 0.8 CI, 16.67% were interventions for “foul odor”, 22.27% for “wound with exudates”, 22.22% of interventions for “oncological pain”, and 12.50% for “infection”.
The main aim of the therapeutic approach in the care of the malignant tumor wound is no longer wound healing, but a focus on patient comfort about the wound and the prevention
Nursing interventions for the diagnosis, “Infection” 1- Apply wound dressing.
2- Implement aseptic technique when caring for malignant wound. 3- Apply topical therapy with appropriate solution.
4- Perform debridement.
5- Apply topical antibiotic therapy in wound. 6- Assess the susceptibility for wound infection. 7- Assess the need to administer antibiotics. Nursing interventions for the diagnosis, “Necrosis” 1- Assess the need for debridement.
2- Perform debridement. 3- Apply wound dressing.
4- Assess the need to administer antibiotics. Continuation
References
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be developed and offer a more reflective, evi-dence-based, practice for the patient with ma-lignant tumor wounds. The ICNP® subsets pro-vide an opportunity for nurses to organize their work process, being able to optimize the time available to the patient during the provision of care Similarly, the ICNP® allows the existence of a common language for all nurses, facilitating communication among themselves as well as a record of their actions. A common, adequate and shared language can contribute to the consolida-tion of the nursing work process, as a member of a multidisciplinary team, with its well-defined competence and awareness of its importance and contribution to the completeness and resolute-ness of care. The complexity and uniqueresolute-ness of patient care with a malignant tumor wound justifies quantitative diagnoses and interven-tions validated by expert nurses, which aims to include the different models of palliative care, which are hospital, home and outpatient care. The lack of knowledge mentioned by the partic-ipants regarding the ICNP® and palliative care was initially identified as a possible limitation of the study, but the high validation index demon-strated the relevance of the proposal and the im-portance of the results achieved.
Collaborations
Castro MCF participated in the design, analysis, data interpretation and writing of the article. Fuly PSC collaborated with the analysis, interpretation of data, relevant crit-ical review of the intellectual content, and final approval of the version to be published. Garcia TR participated in the design, analy-sis, data interpretation and critical review of relevant intellectual content. Santos MLSC contributed to the relevant critical review of the intellectual content.
